National Accountability Mechanisms for Women s and Children s Health

National Accountability Mechanisms for Women s and Children s Health Report commissioned by the Partnership for Maternal, Newborn & Child Health (PMNCH) to inform the PMNCH 2012 report on commitments to the Global Strategy for Women s and Children s Health Final version September 2012 1

Contents Acronyms... 3 Executive Summary... 4 1. Introduction... 7 1.1 Methodology... 7 2. Background... 8 3. Accountability... 10 4. National accountability mechanisms for RMNCH... 12 4.1 Annual Health Sector Review... 13 4.2 National Commissions for Women s and Children s Health... 16 4.3 Country Countdown event... 17 4.4 The International Health Partnership and Related initiatives (IHP+)... 18 4.5 Health issue-specific and disease-specific reviews... 19 4.6 Civil society approaches... 20 4.6.1 Social accountability approaches... 20 4.6.2 Budget tracking... 23 4.7 Human rights based approaches... 25 4.8 Parliament... 27 4.9 The Media... 28 4.10 Common challenges to stronger accountability... 30 5. Conclusions and recommendations... 32 Annex 1: Examples of social accountability mechanisms... 33 Annex 2: List of individuals consulted... 34 2

Acronyms AIDS ALMA CARMMA CCM CEDAW CIDA COIA CSO DHS DPT FMoH GFATM HEPS HIV HMIS ICT ierg IHP+ IMNCI IPU JANS JAR JFA KNCHR M&E MDG MICS MNCH MoH MoHP NAC NCWC NGO NMS PMNCH PMTCT RMNCH SCF UK SUN SWAp TB UNAIDS UNICEF WHO Acquired Immunodeficiency Syndrome African Leaders Malaria Alliance Campaign on Accelerated Reduction of Maternal Mortality in Africa Country Coordinating Mechanism Convention on the Elimination of All Forms of Discrimination Against Women Canadian International Development Agency Commission on Information and Accountability for Women s and Children s Health Civil Society Organization Demographic and Health Survey Diphtheria, Pertussis and Tetanus Federal Ministry of Health Global Fund to Fight AIDS, Tuberculosis and Malaria [Coalition for] Health Promotion and Social Development (Uganda) Human Immunodeficiency Virus Health Management Information System Information Communication Technology independent Expert Review Group International Health Partnership and Related Initiatives Integrated Management of Neonatal and Childhood Illness Inter-Parliamentary Union Joint Assessment of National Strategies Joint Annual Review Joint Financing Arrangement Kenya National Commission on Human Rights Monitoring and Evaluation Millennium Development Goal Multiple Indicator Cluster Survey Maternal, Newborn and Child Health Ministry of Health Ministry of Health and Population (Nepal) National AIDS Commission National Commission for Women and Children (Bhutan) Nongovernmental Organization National Medical Stores (Uganda) Partnership for Maternal, Newborn & Child Health Prevention of Mother-to-Child Transmission Reproductive, Maternal, Newborn and Child Health Save the Children Fund, United Kingdom Scaling Up Nutrition (movement) Sector-wide Approach Tuberculosis Joint United Nations Programme on HIV/AIDS United Nations Children s Fund World Health Organization 3

Executive Summary This report was commissioned by the Partnership for Maternal, Newborn & Child Health (PMNCH) to inform the PMNCH 2012 report on the implementation of commitments to the Global Strategy for Women s and Children s Health. It reviews national accountability mechanisms for women s and children s health. It identifies examples of good practice and innovation and continuing obstacles to improved accountability. The Global Strategy for Women s and Children s Health was the most recent of a number of high-profile initiatives in recent years to improve reproductive, maternal, newborn and child health (RMNCH). These efforts have led to major gains in health outcomes and reductions in maternal, newborn and child mortality with rapid progress in many countries; although in others progress has been more limited or has stalled. There is consensus that effective accountability holds the key to progress, and the Global Strategy highlighted the need for an effective accountability mechanism to track progress. The WHO-initiated Commission on Information and Accountability (COIA) for Women s and Children s Health subsequently developed a framework to strengthen reporting and oversight. Accountability encompasses three interrelated ideas; monitoring, review and action. It is a cyclical process that assesses progress, recognizes success, identifies problems, takes action where indicated and holds all parties to account. Accountability should be a constructive and balanced process. The country level is where improvements to women s and children s health will be made and is the centre of accountability, including reporting against regional and international commitments. An effective accountability mechanism should be transparent and inclusive, ensuring the meaningful participation of all key stakeholders, particularly civil society. Accountability should be informed by subnational reviews that consider data disaggregated by equity concerns. Review should consider data from the widest range of sources and should ideally include independent review. The RMNCH landscape in many countries is complex and fragmented. In many cases, projects are not aligned to the national plan and monitoring framework and work in parallel to government efforts. This leads to fragmented performance frameworks, and multiple systems. This can hinder government efforts to maintain a comprehensive overview of progress. Managing multiple performance frameworks and reporting requirements can incur high transaction costs for government and divert attention from performance management of the whole sector. Investment in a small number of health issues has often led to an imbalanced health sector with distorted incentives. The above scenario is a not an atypical starting point for efforts to improve accountability for RMNCH. There are a number of well-established accountability mechanisms relevant to RMNCH at country level. These include health sector reviews, programme reviews, country Countdown to 2015 events, International Health Partnership reviews, a range of civil society approaches (including social accountability mechanisms human rights 4

treaty approaches), and parliamentary oversight. The media can also play an important role. Accountability for women s and children s health is typically the responsibility of the Ministry of Health (MoH) and many of the core indicators proposed by the COIA are monitored within existing sector results frameworks. However, other sectors of government play an important role in improving RMNCH outcomes, for example ministries of education and agriculture. Reducing deaths of women and children is more than a technical problem for the health sector and needs to be addressed across government. The outcome of reviews should be reported to the head of state and parliament. Despite challenges the health sector review is the most appropriate starting point to strengthen accountability. The MoH typically leads a review of progress in implementation of the national health plan along with its development partners. This process has been best developed in countries that have adopted a sector-wide approach (SWAp) to health. However, the process can be made more inclusive, transparent and effective with greater attention to accountability to citizens and service users. Health sector reviews would gain greater legitimacy by ensuring the meaningful inclusion of all RMNCH stakeholders as full partners in the review process. This includes other government departments whose activities impact on health, parliamentarians, health-care professional organizations, civil society organizations (particularly women's groups), the private sector and academia. There are existing coalitions in some countries that provide a ready forum for this dialogue to take place. A number of initiatives can complement a health sector review including, for example, a country-specific Countdown event or an independent review as part of the International Health Partnership (IHP+). The potential role of parliament and the media is often under-exploited. The concept of an independent Commission for Women and Children is attractive to many but there appears to be limited experience in the focus countries with the greatest needs, and mixed experience with National AIDS Commissions. Reviews typically use a mix of routine health facility data and household survey data. Health facility data generated through the health information system (HMIS) is often incomplete and of variable quality. Efforts to strengthen the HMIS and establish vital registration systems are progressing slowly. The review should employ all possible sources of information including that generated through civil society approaches such as service scorecards, social audits and budget tracking exercises, and studies on compliance with human rights obligations. There are opportunities to improve the analysis and presentation of findings in advance of the high-level review and to make the review more strategic and focused on action. Budget transparency is still a huge challenge in many of the countries with high levels of maternal and child deaths, and is often the weakest part of the accountability cycle. Where health budgets are limited, governments may have limited room for manoeuvre and the Ministry of Finance/Treasury may be resistant to calls to increasing the health budget and having financial targets for RMNCH. Health is one of many competing priorities facing governments of poor countries. 5

Recommendations to improve national accountability mechanisms 1. Strengthen the health sector review (the most pragmatic accountability mechanism in most focal countries) to make it more inclusive, transparent and strategic in its operations. The outcome and recommendations should be shared with the head of state and parliament, and compliance in implementing recommendations improved. 2. Improve accountability to citizens through expanding social accountability approaches, monitoring human rights treaty obligations, partnership with the media and parliamentary oversight. 3. Consider all sources of information when reviewing progress and increase the quality of preparatory work through appraisals that feed findings and clear recommendations into the review. 4. Increase alignment and integration of all RMNCH support behind a single national plan and monitoring framework that builds upon and strengthens the existing system. 5. Invest in building capacity of civil society organizations (CSO), the media and parliamentarians to better monitor and use evidence for advocacy and to hold governments to account on RMNCH commitments. 6

1. Introduction This report reviews country accountability mechanisms for women s and children s health. It seeks to identify examples of good practice and innovation and continuing obstacles to improved accountability. It was commissioned by PMNCH to inform the PMNCH 2012 Report on the implementation of commitments to the Global Strategy for Women s and Children s Health, and complements a PMNCH-commissioned study on global accountability mechanisms published in 2011. 1 1.1 Methodology It was anticipated that two concurrent exercises would identify country examples for more detailed study; the call by the Independent Expert Review Group (ierg) for examples of best practice on country accountability; and the online questionnaire sent by PMNCH to all stakeholders that made commitments to the Global Strategy. Unfortunately, responses to both data collection efforts were limited at the time of writing this report and therefore did not provide a steer to good practice. Additional information submitted to the ierg and PMNCH will be presented in the respective reports to be released in September 2012. The PMNCH Secretariat provided initial guidance on key informants and an initial round of interviews provided links to further informants for follow up and semistructured interviews. Document search included review of commitments on accountability, responses to the online questionnaire, and review of county selfassessments presented at the series of subregional workshops to develop country accountability roadmaps for implementation of the recommendations by the Commission on Information and Accountability (COIA) for Women s and Children s Health. 2 1 See http://www.who.int/pmnch/topics/part_publications/2011_accountability-mechanisms/en/ 2 See http://www.who.int/woman_child_accountability/accountability_workshops/en/index.html 7

2. Background In September 2010 the United Nations Secretary-General launched the Global Strategy for Women s and Children s Health. 3 This call to action aimed to increase visibility and political support, mobilize resources and catalyse a renewed effort to accelerate progress towards the achievement of relevant Millennium Development Goals (MDGs). Thirty-seven heads of state made statements of intent or specific commitments at the launch, and more than 200 specific commitments totalling more than US$ 50 billion have subsequently been made. The launch was the latest of a number of high-profile initiatives in recent years to improve reproductive, maternal, newborn and child health (RMNCH). These include the Millennium Summit (2000), Countdown to 2015 (2005, 2008, 2010, 2012), the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) (2009), the Women Deliver conferences, and the G8 Muskoka summit (2010). 2012 will see the launch of further high-level initiatives on family planning and child survival. For example, the Commission on Life-Saving Commodities for Women s and Children s Health, launched on 23 March, aims to increase access to life-saving medicines and health supplies by addressing barriers that limit access to essential health commodities. The goal of Committing to Child Survival: A Promise Renewed, held on 14-15 June 2012, is to end preventable child deaths. The Family Planning Summit in July 2012 aims to generate political commitment and resources to meet the family planning needs of women in the world s poorest countries by 2020. The momentum has increased as 2015 approaches and the MDGs and targets related to RMNCH risk not being met. These efforts have led to major gains in health outcomes and reductions in maternal, newborn and child mortality with rapid progress in many countries, but in others progress has been limited or stalled. There is consensus that accountability holds the key to progress. At the request of the Secretary-General, WHO established the Commission on Information and Accountability for Women s and Children s Health (COIA). 4 This group proposed a framework to strengthen reporting and oversight and to encourage countries and their partners to be more accountable for women s and children s health. In setting accountability primarily at the country level the Commission highlighted the need for more active collaboration between national governments, development partners, parliaments, civil society and communities. In relation to the need for better oversight of results and resources nationally and globally the Commission recommended that:...by 2012 all countries to have established national accountability mechanisms that are transparent, that are inclusive of all stakeholders, and that recommend remedial action, as required. The Commission recommended the adoption of 11 core indicators (broadly related to better information, better tracking of resources and stronger oversight) to track progress across the continuum of care. An important element was the need to for all data to be disaggregated by key equity considerations. 3 United Nations Secretary-General. Global Strategy for Women s and Children s Health (2010). 4 Commission on Information and Accountability for Women s and Children s Health. Keeping Promises, Measure Results. United Nations (2011). 8

The Secretary-General subsequently appointed an independent Expert Review Group (ierg) to report annually on progress in implementing the Commission s recommendations regarding reporting, oversight and accountability in 75 priority countries 49 low-income countries and 26 other countries with high maternal and child mortality and to assess the extent to which all stakeholders honour their commitments to the Global Strategy and the Commission. 9

3. Accountability Commitments relating to reproductive, maternal, newborn and child health (RMNCH) date back to the Convention on the Rights of the Child in 1989 and the International Conference on Population and Development in 1994 but have often not been implemented with the necessary urgency and at scale. This has often reflected lack of adequate resources, competing development priorities in the social and other sectors but at times also a lack of leadership and accountability. Accountability will be key to the success of the strategy. Accountability can push partners to deliver on their commitments and responsibilities, demonstrate how actions and investment translate into tangible results and better long term outcomes, and tell us what works, what needs to be improved and what requires more attention. Accountability mechanisms that give women, girls and communities the ability and channel through which to challenge and demand change can be empowering. Accountability encompasses three interrelated ideas; monitoring, review and action. 5 It is a cyclical process to assess progress, recognize success, identify problems, take remedial action and hold all parties to account. It looks at commitments and what actually happened and, where appropriate, provides practical recommendations on what might be done better. It should be a combination of political, managerial and social accountability. Monitoring is about finding out what is happening, where and to whom and what is not happening. Review asks whether or not pledges, promises and commitments have been kept and duties discharged. It asks what good practices can be learned. It highlights geographical, political and social differences and inequities. It asks why commitments were not delivered (and there may well be legitimate reasons for this). Remedy or action refers to measures needed to put things right if they have not gone as promised or planned. This can take many forms; perhaps revisions to a policy, programme, project or budget. At times perhaps full disclosure and a public apology. Informed self-accountability is important but history tells us that it may not be enough. An independent perspective is important to ensure objectivity and to ensure legitimacy and credibility of the process. Ideally an independent body should be involved to provide answers to these questions: a small, trusted, adequately resourced, transparent, review mechanism. Accountability should be a constructive and balanced process. However, it can at times be seen as a threatening exercise, particularly if there is a history of punitive rather than supportive measures if progress is poor. The landscape is populated by a number of global, regional and national RMNCH initiatives that are working to similar ends. Throughout this exercise the question was raised, accountability for what and to whom? delivering the Global Strategy or implementing the recommendations of the COIA, implementing the National Health Strategic Plan or National Development Plan, realizing the MDGs or all of these? 5 See http://www.who.int/pmnch/topics/part_publications/2011_accountability-mechanisms/en/ 10

While global and regional initiatives provide helpful and supportive frameworks, it is action at the country level that will make the difference to the lives of women and children and where accountability for improved outcomes needs to be focused. Enhanced accountability is required at many levels: between both state and nonstate providers and women and wider communities and between governments and parliaments and their citizens and civil society; within the health systems for better performance; and across the aid architecture. 11

4. National accountability mechanisms for RMNCH The national level is the anchor of all international institutional arrangements including reporting against regional and international obligations. The nature of accountability mechanisms for RMNCH varies from country to country but they should be transparent and inclusive, ensuring that all key stakeholders are adequately represented. Accountability should span subnational, district and local levels. It should allow review of disaggregate data by equity concerns and consider all sources of information. The ierg established a number of key operating principles to improve accountability: To focus on national leadership and ownership of results; To strengthen countries' capacity to monitor and evaluate; To reduce the reporting burden by aligning efforts with the systems used to monitor and evaluate national health strategies; To strengthen and harmonize existing international mechanisms to track progress on all commitments made. Accountability for women s and children s health is typically the responsibility of the Ministry of Health (MoH). Many of the core indicators proposed by the COIA are monitored within existing health sector performance frameworks. However, other sectors of government play an important role in improving RMNCH outcomes, for example ministries of education, women s and children s affairs, justice, finance and community services. A MoH-led review process may be limited to health sector interventions and fail to take a comprehensive overview. There is a need for high-level leadership beyond health and it is important that the outcome of reviews be shared with the head of state and parliament (see Box 1 for an example from Ethiopia). Reducing deaths of women and children is more than a technical problem for the health sector but is also a national development priority that requires action across government. Box 1 Ethiopia High-Level Leadership The Ethiopian context is marked by a strong commitment at the highest levels to address maternal, newborn and child mortality. The Federal Minister of Health, who served on the COIA, is an identified champion for change. The Prime Minister s office requests regular updates of sector performance reports within two weeks of the end of each quarter. The MoH presents its nine months performance report to parliament each year. The Health Sector Development Plan sets out guiding principles to achieving its strategic aims: government leadership; enhanced responsiveness to community needs; and comprehensive coverage of priority health sector issues (which includes RMNCH). A culture of accountability exists for RMNCH, particularly in reducing maternal mortality. Each level of health provision is held to account for progress through a series of internal review processes, including the Annual Review Meeting during which data from the health information system are reviewed and progress against national targets openly discussed. Results emerging from the 2011 Demographic and Health Survey (DHS), suggesting stagnation in the country s maternal mortality rate and continuing low levels of delivery in health facilities by a skilled birth attendant, have led to increased impetus for action. An accelerated RMNCH strategy was issued in response. The FMoH, with the support of its partners, is investing 62% of the MDG performance fund (a pooled fund under government control) in 12

strengthening the health system, including strengthening the health extension programme, improving maternal health care at facility level and improving referral. Federal Ministry of Health, Ethiopia The health and development landscape in many countries may not facilitate a rational and efficient process of accountability. Development partners may work outside the national plan and budget and in parallel with national systems, which can undermine government leadership. This can create a fragmented response with duplication in some areas and gaps in others. It can lead to a complex mix of plans, systems, procedures and monitoring frameworks. Investment in a few important health issues but not others has led to an imbalanced health sector and distorted incentive systems in a number of countries. The coordination and management of many partners can create a major burden for governments. The above scenario is a common starting point in a number of focal countries when improving accountability for RMNCH. The International Health Partnership+ (see below) mobilizes partners around a single country-led national health strategy with accountability at the centre. Where a number of initiatives have overlapping goals there is benefit in integrating efforts. In March 2012 over 140 partners gathered in Kampala to implement the Integrated Strategy for Reproductive, Maternal, Newborn and Child Health (RMNCH), led by the African Union. Participants included parliamentarians, representatives of ministries of health, NGOs, health-care professional associations, the media, the private sector, United Nations agencies, academia, donors and youth representatives. The strategy promotes alignment of several African and global frameworks for women s and children s health, including the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA), 6 the Maputo Plan of Action 7 and the Global Strategy. Partners committed to launch country Countdown to 2015 events (see below) to underpin national advocacy efforts. They noted the importance of key stakeholders, especially parliamentarians, media and youth, in ensuring accountability for results and resources and committed to support capacitybuilding efforts targeting these groups. A number of well-established accountability mechanisms exist at country level. These include health sector reviews, health and disease specific reviews that may be linked to funding sources, civil society approaches around citizen voice and social accountability including budget tracking and human rights based approaches. Each has an important role in enhancing accountability. 4.1 Annual Health Sector Review A common approach is the health sector review whereby government, most often through the MoH together with development partners, leads an annual/biannual review of progress of implementation of the national health plan. These are often most developed in countries that have adopted a sector-wide approach (SWAp) to 6 The Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) is an African Union Commission (AUC) and UNFPA initiative to intensify the implementation of the Maputo Plan of Action for the reduction of maternal mortality in the Africa region. Launched by the African Union (AU) Ministers of Health in May 2009. see http://au.int/pages/carmma/whatis 7 The Maputo Plan of Action to curb maternal deaths in Africa was launched in September 2006 by Ministers of Health and delegates from 48 African countries in Maputo, Mozambique where they adopted a plan of action to ensure universal access to comprehensive sexual and reproductive health (SRH) services on the continent. See http://au.int/pages/carmma/maputo 13

health (see Box 2). The SWAp stresses the importance of country leadership, a single sector policy, expenditure and monitoring framework, and use of common approaches across the sector. It accommodates different funding instruments but progresses towards reliance on government systems to disburse and account for funds. The performance of reviews has evolved in many countries over a decade and moved from a government (MoH) donor relationship to a more inclusive forum that commonly includes representatives of civil society, parliament and the private sector. Box 2 The Sector-wide Approach in Ghana, Rwanda and Tanzania Ghana, Rwanda and Tanzania 8 have developed systems of monitoring, review and based on many years of experience with sector-wide approaches (SWAp) in the health sector. The health sector strategy is linked to the national strategies for growth and development and poverty reduction. There is a consistent link between reviews and resource allocation through medium-term expenditure frameworks and annual planning cycles and subnational processes of review and action. National monitoring of progress and performance focuses on a core set of indicators: 18 in Rwanda, 37 in Ghana and 40 in Tanzania. RMNCH indicators account for at least half of these and are also prominent in the monitoring component of overall development plans. Data availability and quality have improved during the past decade, mainly due to more frequent health surveys. The monitoring input in annual reviews is largely based on facility and administrative data sources with problems of availability, completeness and quality of data. Data on births and deaths/cause of death is lacking in all three countries. Off-budget spending by development partners is not routinely tracked. The institutional mechanisms to support critical elements of monitoring, including data quality assessments, data sharing, analysis and synthesis, and communication of results are recognized to need strengthening in all three countries. These functions are concentrated in the MoH where there is limited capacity. The involvement of key country institutions and independent assessment should be an integral part of the monitoring process. Health sector reviews and planning summits are conducted on at least an annual basis with broad stakeholder involvement. Development partner participation is prominent, but the civil society role is less clear. Many, but not all, development partners have aligned themselves with these country-led monitoring/review processes. Maternal, newborn and child health (MNCH) appears high on the political agenda in the three countries. All three countries have roadmaps and plans to accelerate progress towards MDGs 4 and 5. Commitments to the Global Strategy are linked to national strategies and seen as an additional opportunity to strengthen implementation. The MNCH reviews include programme specific reviews and are embedded in the well-established national system of reviewing progress and performance. 8 Accountability for women's and children's health in countries - Current practices and challenges in Ghana, Rwanda and Tanzania - A case study prepared for the Commission on Information and Accountability for Women's and Children's Health. WHO, 20 April 2011. 14

ierg There are many common features of the sector review that countries identify as requiring strengthening. This section draws on the country self assessments presented during the series of subregional workshops to develop country accountability roadmaps (see Box 3). 9 Wider and more meaningful participation Sector reviews demonstrate varying levels of inclusion for example, participation of other government sectors whose activities impact on health such as education or women and children s affairs. Dialogue can be too focused on development partners and government and meaningful participation of CSO and the private sector may not be encouraged. Parliamentarians role, while increasing, may also be limited. The participation and representation of women's groups in the reviews can be improved in many countries. Many countries have parliamentary committees, networks or caucuses on health, reproductive health, population and development, or gender and poverty alleviation with opportunities for closer collaboration. Not all development partners are engaged in the process. Improved quality of information and more robust analysis of data Routine data collection through the routine health management information system (HMIS) is often weak and may not be linked to the Central Statistical Office and other involved ministries. The HMIS has many gaps; in management, staffing and infrastructure. Despite the presence of a single monitoring framework partners may continue to employ a multiplicity of tools to monitor progress. In many cases the validation, disaggregation and coverage of data need improvement. Better preparation and more strategic review process The health sector review takes a comprehensive overview of the sector at a high level. More detailed preparatory appraisal processes for RMNCH can condense main findings to enable the review to focus on action points. Reviews are informed by analysis of qualitative data (e.g. policy changes, public opinion, service provider opinions) and quantitative (HMIS, survey) data but analysis could be more systematic and include information from the widest range of sources. Greater attention to action Challenges remain in translating the review findings into at all levels and in monitoring compliance with recommendations. Greater transparency and improved dissemination of information Review reports can be made available online, and packaged in accessible formats for different audiences including parliament and the media. 9 See http://www.who.int/woman_child_accountability/en/ 15

Box 3 Countries develop country accountability roadmaps A series of regional workshops is under way involving the 75 priority countries and regional and global partners to develop country roadmaps to strengthen national accountability and action for improving women s and children s health. The work is part of the action plan to implement the recommendations of the Commission on Information and Accountability and organized by WHO. Country participants assess their situation and develop draft roadmaps for enhancing accountability in seven key areas: monitoring of results, tracking resources, civil registration and vital statistics, maternal death reviews, strengthening the use of information and communication technology (ICT) and advocacy and action. A country accountability tool with suggested criteria for progress in each area is used by delegations to identify strengths and weaknesses and define appropriate actions for their country. The draft will be further developed through wider consultation in each country and funding provided to support the process. Feedback on the workshops and the assessment tools has been positive. While focused on strengthening accountability for women s and children s health, the framework will complement and strengthen accountability across the wider health sector. PMNCH 4.2 National Commissions for Women s and Children s Health A potential option to strengthen review mechanisms in countries is to establish a national commission for women s and children s health along the lines of a National AIDS Commission (NAC). Such a body would be independent, chaired by a respected senior individual and would report to parliament. It would be inclusive of all relevant government departments, and would engage nongovernmental organizations. The concept of an independent Commission for Women and Children is attractive (see Box 4) but there appears to be limited experience in the focus countries with the greatest needs. Box 4 The Bhutan National Commission for Women and Children (NCWC) Established in 2004, the National Commission for Women and Children (NCWC) is an autonomous institution of the Government of Bhutan. The NCWC is the national mechanism for coordinating and monitoring activities related to women s and children s rights, and reporting to treaty bodies. It is governed by a Chairperson, the Minister of Education, and a Board of Commissioners from the police, judiciary, NGOs, civil society, academia, private sector and line ministries. The Commission has a cross-sectoral and mixed representation of members from the government, law enforcement, judiciary, social sector and civil society, including the media and the business sector. National Commission for Women and Children, Royal Government of Bhutan The COIA considered the experience of NACs in leading the multisectoral response to HIV/AIDS. A suggestion was made to extend the remit of NAC to encompass RMNCH. The NAC took many years to establish and many have since been disbanded. Experience of the NAC mechanism has been mixed with evaluation highlighting a number of concerns. Although the NAC was responsible to coordinate 16

the national response across sectors, including civil society and the private sector it was often seen as a public sector body with minimal or tokenistic representation of interest groups. The creation of a multisectoral institution did not necessarily foster a multisectoral approach. The NAC promoted the three ones concept which subsequently had to adapt to the separate mechanism related to Global Fund grantsthe Country Coordinating Mechanism. 10 The lack of lines of accountability to ministries and the establishment of the NAC as standalone institutions created political tensions with the MoH and undermined the ability of the MoH to deliver the health sector response to HIV. The leadership of the AIDS response has often returned to the MoH. The World Bank OED 2005 evaluation concluded that evidence to support the effectiveness of institutions to manage the AIDS response outside of the MoH from the World Bank s experience is scant. 11 Lessons from the AIDS response of relevance to RMNCH are the success of incountry processes such as common planning and reviews around the three ones concept the inclusion of civil society and their prominent role in the response, and the reporting obligations against international commitments to United Nations General Assembly Special Sessions on HIV/AIDS. The NAC model did manage to engage the highest level of government in the response, a vital link that the health sector review has failed to achieve in some countries. 12 4.3 Country Countdown event Launched in 2005, Countdown is a global movement of academics, governments, international agencies, health-care professional organizations, donors and NGOs with The Lancet health journal as a partner. Countdown gathers household survey data (Demographic and Health Surveys [DHS], Multiple Indicator Cluster Surveys [MICS]) from the 75 countries where 95% of MNC deaths occur. It provides a regularly updated snapshot of coverage levels of effective interventions, health systems functionality, health policies, financing, and equity. The latest Countdown report was released in June 2012. 13 Countdown supports countries in utilizing Countdown data, methodological approaches, reports, and conferences as a means of catalysing national progress and ensuring accountability. Senegal held the first national Countdown conference in 2006, bringing together government leaders, private and public partners, and the research community to review progress in child survival. Zambia held a national Countdown event in 2008, resulting in significant actions to improve maternal, newborn, and child health by the government and other stakeholders. Nigeria has embarked on an Integrated Maternal, Newborn and Child Health Strategy that includes the regular production of up-to-date child and maternal health profiles for each of its 36 states, modelled on the Countdown country profiles. More countries plan to hold country Countdowns from 2012. 10 Three Ones: One agreed HIV/AIDS action framework that provides the basis for coordinating the work of all partners, one National AIDS Coordinating Authority, with a broad-based multisector mandate, one agreed country level monitoring and evaluation system. 11 ELDIS HIV/AIDS Key issues Guides: National AIDS Commissions 2007. 12 UNAIDS interviews. 13 http://www.countdown2015mnch.org/reports-and-articles/2012-report 17

4.4 The International Health Partnership and Related initiatives (IHP+) IHP+ was launched in 2007 with the objective to accelerate progress towards the health related MDGs through a commitment of developing country governments and development partners to work effectively with renewed urgency to build sustainable health systems and improve health outcomes in low and middle income countries. It mobilizes partners around a single country-led national health strategy with accountability at the centre. The initiative is essentially about improving the effectiveness of aid and implementing the Paris/Accra principles in the health sector (national ownership, alignment with national systems, harmonization between agencies, managing for results, mutual accountability). IHP+ includes 25 development partners and 24 countries (see Box 5 for an example). Partners commit to annually undertake an independent evidence-based assessment of results at country level and of the performance of each partner individually and collectively. It has developed well received common tools such as Joint Assessment of National Strategies (JANS). Data is presented as a set of accessible performance scorecards for each country and partner. IHP+ highlights the impact of fragmented performance frameworks, information systems and project based monitoring in hindering government efforts to maintain a comprehensive overview of progress. The management of such multiple performance monitoring reports incurs high transaction costs for government. Despite countries having a single performance assessment framework including a mix of health and system indicators this has not reduced requests for additional indicators. It is too early to judge if the IHP+ is contributing to stronger health systems or improved health outcomes. Box 5 Nepal- IHP+ Independent monitoring of progress Since the MoHP and external development partners signed the 2004 Statement of Intent to guide the Partnership for Health Sector Development, Nepal s health partnership and performance review mechanisms have evolved considerably. Joint annual reviews of health sector performance have been held since 2005. Partnership agreements, or compacts, have become progressively more explicit. The 2010 Joint Financing Arrangement (JFA), signed by the government and 10 development partners, emphasized the Joint Assessment Review (JAR) as the single joint review mechanism for all partners to monitor progress against agreed priorities and results. It contained common procedures for monitoring and reporting. Preparation for the JAR is becoming progressively more systematic, and discussions during the JAR more strategic. Improving maternal and child health is a major priority in the current National Health Sector Development Programme 2010-15, and in the 2012 JAR the priority topics were maternal and child health, health workforce, monitoring and evaluation, financial management and medicines procurement and distribution. In the 2012 JAR external development partners reported back on progress on their own commitments in partnership documents for the first time. The government of Nepal confirmed that the Ministry of Finance s new Aid Management Platform, which will contain external development partner and NGO data, is to be extended to sector level during 2012 and will be publicly available. The 2012 JAR Aide Memoire stated that an holistic costed M&E plan would be ready by mid-2012. An additional route to increasing accountability is the independent monitoring of progress by IHP+ Results against commitments made by signatories to the IHP+ Global Compact: Nepal has participated in 2010 and 2012. 18

4.5 Health issue-specific and disease-specific reviews International Health Partnership (IHP+) The health sector review is the main national accountability mechanism for overall performance against the national health plan. However, there are parallel accountability mechanisms that are related to specific health issues, diseases or funding sources. In recent years major effort and resources have been directed to HIV/AIDS, TB and malaria and childhood immunization which have separate accountability mechanisms that involve a wide range of stakeholders. The Country Coordinating Mechanism (CCM) for Global Fund Grants has increased local ownership and participatory decision-making. These country-level partnerships develop and submit grant proposals to the Fund based on priority needs at the national level and oversee progress during implementation. The CCM includes representatives from both the public and private sectors, including governments, multilateral or bilateral agencies, nongovernmental organizations, academic institutions, private businesses and people living with the diseases. While increasing inclusion and participation they have added substantially to transaction costs for government. Since 2010 high-profile initiatives have been launched against noncommunicable diseases 14 and under-nutrition (Scaling Up Nutrition-SUN). 15 Advocates for each argue rationally for the need for accelerated attention for a long neglected issue of global importance and call for the need for substantial resource mobilization. Plans include a new accountability framework. Multiple, often-competing initiatives with separate accountability mechanisms and data collection systems that may work in parallel to the HMIS is a problem for ministries as they strengthen their national systems. There is no ready solution as support is often linked to performance and the requirement for high-quality data. In 2012, three linked initiatives take up key challenges set out by the Global Strategy: The United Nations Commission on Life-Saving Commodities for Women and Children aims to ensure better access to life-saving commodities for women and children; A Promise to Keep: Ending Preventable Child Deaths is a new movement calling for better accountability and targeted life-saving interventions for children over the next two decades. A Family Planning Summit will aim to generate unprecedented political commitment and resources from developing countries, donors, the private sector, civil society and other partners to meet the family planning needs of women in the world s poorest countries by 2020. It will be important to ensure that the focus on particular elements of the overall RMNCH strategy does not divert attention from the need to implement the whole strategy for women and children and in doing so undermine the consensus that has been built up around the continuum of care over recent years. It will be important that accountability and reporting related to these initiatives is consistent with national accountability mechanism and follows the principles set out by the COIA. One targeted initiative has engaged heads of states in the accountability process. The African Leaders Malaria Alliance (ALMA) was launched in 2009 to reach 14 Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Noncommunicable Diseases. http://www.who.int/nmh/events/un_ncd_summit2011/political_declaration_en.pdf. United Nations November 2011. 15 Scaling Up Nutrition (SUN); www.scalingupnutrition.org 19

universal prevention and coverage of malaria interventions by 2010 and eliminate preventable deaths by 2015. 16 The stated aims include keeping malaria high on the political and policy agenda at all levels. ALMA employs a visual scorecard to enhance accountability and track progress. The scorecard includes four MNCH indicators (PMTCT, skilled attendance at birth, exclusive breast feeding, immunization coverage with DPT3). While this is a bonus for the visibility and focus on malaria it may divert attention from wider health challenges. 4.6 Civil society approaches Accountability is commonly viewed as a government donor and donor government relationship but is also about government accountability to its citizens and responsiveness to populations' expectations of the health service. Enhanced accountability is required at many levels: between both state and non-state providers and women and wider communities and between governments and parliaments and their citizens and civil society. Civil society has a powerful potential accountability role as a watchdog in holding government to account and a role in advocacy and campaigning (see Box 7). Civil society organizations (CSO) support service delivery, help build capacity in critical skills and pilot new approaches. CSOs are increasingly involved in health planning and review mechanisms and contribute to policy development and debate in some countries but in others are not engaged in a meaningful way. There is scope for stronger partnerships with government but CSO can be perceived as a threat, particularly when challenging government over perceived human rights violations. 4.6.1 Social accountability approaches 17 Social accountability is a bottom up approach in which citizens as service users can affect social services and change behaviour of service providers through their collective voice and influence. There has been increasing interest in recent years in the potential of individuals and communities as users of services and as citizens, as a key force for change. 18 There is increasing use of scorecards and social audits, and use of new information technologies to contribute to social monitoring (see Box 6). Their participation may include initiating campaigns to inform citizens about their rights and what services they are entitled to, performing third-party monitoring through processes such as social audits, and conducting analyses. They may undertake budget analysis and public expenditure tracking surveys to follow the money from central government budgets through to service providers, or absenteeism surveys to monitor attendance of service providers in health facilities. 16 ALMA is an alliance of African Heads of State and Government working to end malaria-related deaths. This body was founded by African Heads of State to utilize their individual and collective power across country and regional borders: see http://www.alma2015.org/ 17 See Annex 1 for examples of social accountability interventions 18 Citizens and Service Delivery; Assessing the Use of Social Accountability Approaches in the Human Development Sectors. Dena Ringold, Alaka Holla, Margaret Koziol,Santhosh Srinivasan. World Bank 2012 20